Provider Demographics
NPI:1285723528
Name:REDSTROM, JEROLYN N (OTR)
Entity type:Individual
Prefix:MRS
First Name:JEROLYN
Middle Name:N
Last Name:REDSTROM
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 W PARK CT
Mailing Address - Street 2:SUITE G/ H
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3500
Mailing Address - Country:US
Mailing Address - Phone:770-465-5084
Mailing Address - Fax:
Practice Address - Street 1:2155 W PARK CT
Practice Address - Street 2:SUITE G/ H
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3500
Practice Address - Country:US
Practice Address - Phone:770-465-5084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003913225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA67BBBMBMedicare ID - Type UnspecifiedMEDICARE PART B PROVIDER